Doctors should have electronic records everywhere possible. It will reduce mistakes and litigation. GPs have been paperless for 20 years..

NHSreality wonders why the Regional Health Services don’t allow GPs on their boards, or to influence Hospital Care records. GPs have holistic notes with complete histories including medical, social, psychological, familial and sometimes spiritual. Patients ideas, concerns and expectations over many years are recorded in readable form. When necessary an ” word for word ” note can be made, and in the litigatious, world all consultations should be recorded. NHSreality prefers audio recording as this is less intrusive to the consultation, but it is also less defensible, and video recording is the likely outcome. Doctors should have digital electronic records everywhere possible. It will reduce mistakes and litigation. (Chris Smyth 17th May 2014 in The Times: Poor writing puts patients’ lives at risk) GPs have been paperless for 20 years.. so why have the hospitals not followed?

In Italy they are accepting their inability to digitalise the medical record, and instead of using Information Technology to improve volumes and performance, they have regressed. Tom Kington in Rome in the Times 1st July 2015 reports: Italian hospitals lose patience with doctors’ illegible scrawl. There is no greater indication of their fossilised economic state than their inability to countenance progressive change. Like the Greeks, the Italians are on the verge of disaster, and an increasein global interest rates and inflation could see them follow their neighbours. There are other advantages such as research, audit, pharmaceutical dose checking, information sheets printed when needed for patients, and lowered paper and printing costs.

Doctors all over the world have long been criticised for their spidery, illegible scribbles. Now an Italian health authority hopes to solve the problem once and for all by demanding that medics write in capital letters only.

The new rule, which will be introduced this year in hospitals in the Lazio region around Rome, will no doubt please patients used to being left in the dark by doctors’ unfathomable hieroglyphics, but it may also save lives.

A survey has shown that of the 320,000 errors recorded in Italian hospitals every year, about half are related to mistakes made in the prescription of patient treatments, and 84 per cent of those mistakes come when nurses or doctors transcribe, with errors, the poorly written or incomplete patient notes made by doctors or surgeons. That leads to the prescription of incorrect medication or therapies to patients, the study found.

“It’s a big problem doctors just write badly,” said Alessandro Boccanelli, the head of the health association that helped carry out the study. “It’s because they are in a hurry. It would be great if they wrote like engineers, not like doctors,” he added.

The financial cost of poorly written patient files is also high, the survey found, noting that there are 12,000 legal cases pending against Italian hospitals for malpractice, with damages requested totalling €2.5 billion.

Dr Boccanelli said: “Many doctors do now type prescriptions on the computer and print them off, but it is not obligatory and it should be. I am sure it would improve patient-doctor relations no end.”

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government.
I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years.
I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS!
I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.